Arch Gynecol Obstet (2004) 270:199–200DOI 10.1007/s00404-003-0497-6

C A S E R E P O R T

Harsh Mohan · Praveen Mohan · Amanjit Bal ·Anita Tahlan

Massive ovarian oedema: report of two cases

Received: 12 February 2003 / Accepted: 19 February 2003 / Published online: 28 June 2003� Springer-Verlag 2003

Abstract Introduction: Massive ovarian oedema is a rareentity characterized by accumulation of oedema fluid inovarian stroma. Clinically it mimics solid ovarianneoplasm and thus requiring histopathological examina-tion to rule out malignancy. Case report: Two cases ofmassive ovarian oedema are presented and the pathogen-esis and management is being discussed.

Keywords Ovary · Oedema · Neoplasm

Introduction

Massive ovarian oedema is a rare tumour-like entityoccurring in young women. It is characterized byenlargement of the ovary by accumulation of oedemafluid in the stroma but preserving the overall ovarianstructure. Till date less than 75 cases have been reportedin the English literature [3]. All solid ovarian masses areconsidered malignant until proven otherwise, thus exclu-sion of the neoplastic process in an enlarged solid ovary isimportant and requires microscopic examination. Wepresent two cases of massive ovarian oedema, clinicallypresenting as ovarian tumour.

Case reports

Case 1

Patient

A 27-year-old female presented with complaints of irregular scantymenstrual flow for the past 8 months. There were no othercomplaints or signs of virilisation. On per vaginum examination,the uterus was retroverted multiparous size. There was a well-defined cystic mass, separate from the uterus, in the anterior fornixmeasuring 6�6 cm. Clinical impression was of right ovarian cyst.Routine investigations were within normal limits. Serum testoster-one levels were normal. Exploratory laparotomy was done.Peroperatively, right ovary was enlarged measuring 6–7 cm, solidto feel with thick capsule and multiple follicles were seen on thesurface of the ovary. Uterus, right fallopian tube and left adnexawere unremarkable. Ovarian cystectomy was done.

Histopathological examination

Grossly it was a soft solid ovarian mass measuring 6�5�3 cm.Outer surface was covered by capsule and was pearly. Small cysticareas of 0.1–0.3 cm diameter were visible under the capsule. Cutsection was grey white glistening with gelatinous areas (Fig. 1).Microscopic examination revealed thick fibrous capsule and cysticfollicles in the superficial cortex. The inner cortex and medullashowed diffuse oedema widely separating the stellate stromal cellsand intervening collagen (Fig. 2). Vascular and lymphatic channelswere prominent. Areas of luteinisation were not seen.

Case 2

Patient

A 19-year-old female came with the complaints of pain left iliacfossa radiating to back for 5–6 days. There were no othercomplaints. Routine investigations were within normal limits.Ultrasonography revealed a solid left ovarian mass. Clinicaldiagnosis of ovarian tumour with torsion was made. Left ovarianmass was removed and right ovary was biopsied.

Histopathological examination

Grossly left ovarian mass measured 9�6�3 cm. It was wellencapsulated with nodular appearance and focal areas of conges-tion. Cut section was predominantly solid, grey white glistening in

H. Mohan ()) · A. Bal · A. TahlanDepartment of Pathology,Government Medical College,Sarai Building, Sector-32A, 160 047 Chandigarh, Indiae-mail: harshmohan@glide.net.inTel.: +91-172-665253

P. MohanDepartment of Obstetrics and Gynaecology,Government Medical College,Sarai Building, Sector-32A, 160 047 Chandigarh, India

appearance with small cysts at the periphery. Microscopic exam-ination showed ovarian stroma separated by abundant oedema fluidand focal areas of haemorrhage. Follicular cysts were present in thecortical region. Right ovarian biopsy showed numerous primordialfollicles with unremarkable stroma.

Discussion

Massive ovarian oedema is an uncommon entity. It affectswomen in their second and third decades and rarely pre-

pubertal girls [4]. Most patients present with acuteabdominal pain or a palpable adnexal mass or rarely withmenstrual disturbances. Virilisation occurs in 10–15% ofcases [5] and hormonal symptoms like precocious pseu-do-puberty and amenorrhoea have also been reported.Right ovary is affected more frequently (two-thirds ofcases) and bilaterality is rarely reported [1].

Massive ovarian oedema has been categorized into twotypes: primary (without concomitant pathology), andsecondary (superimposed on already altered ovaries).Two theories have been proposed to explain its patho-genesis. One is that it results from partial or intermittenttorsion of an otherwise normal ovary compromisingvenous and lymphatic drainage not causing ischaemicnecrosis. Newer theory proposes that it results fromfibroblastic proliferation with abundance of extracellularsubstance [1, 6]. Stromal stellate cells have hormonereceptors and undergo stimulation to produce hormonesand symptoms like virilisation and precocious puberty.

Massive ovarian oedema is to be distinguished fromother ovarian lesions showing oedema. These includeovarian fibromas and thecoma-fibromas, polycysticovaries, sclerosing stromal tumours and ovarian myxo-mas. This can be achieved only by microscopic exami-nation of the enlarged ovary.

Earlier unilateral salpingo-oophorectomy was theprocedure of choice, but these days a more conservativeapproach is followed as patients are young and it isimportant to retain reproductive capacity. This approachincludes intra-operative frozen section of a large wedge ofthe affected ovary to exclude underlying neoplasia andconfirm viability of the ovary and then tethering of theovary to the uterus [2].

References

1. Antoniuk P, Tjandra J, Lavery C (1993) Diffuse intra-abdom-inal fibromatosis in association with bilateral ovarian fibroma-tosis and oedema. Aust NZ J Surg 63:315–318

2. Hill LM, Pelekanos M, Kanbour A (1993) Massive oedema ofan ovary previously fixed to the pelvic side wall. J UltrasoundMed 12:629–632

3. Nogales FF, Martin-Glacia E, Salamanca A, Gonzales-NunezMA, Mindan FJP (1996) Massive ovarian oedema. Histopa-thology 28:229–234

4. Roth IM, Deaton RL, Sternerg WH (1979) Massive ovarianoedema—a clinicopathological study of 5 cases includingultrastructural observation and review of the literature. Am JSurg Pathol 3:11–21

5. Vasquez RH, Scully RE (1984) Fibromatosis and massiveoedema of ovary and virilisation. Obstet Gynaecol 59:S95–S99

6. Young RH, Scully RE (1984) Fibromatosis and massiveoedema of the ovary, possibly related entities: a report of 14cases of fibromatosis and 11 cases of massive oedema. Int JGynecol Pathol 3:153–158

Fig. 2 Photomicrograph showing massive oedema of the ovarianstroma separating the stromal stellate cells (H&E, �100)

Fig. 1 Gross photograph of enlarged ovary involved by massiveoedema. Sectioned surface shows grey white homogeneousglistening and gelatinous appearance

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